Tuesday, 19 April 2011

Although Nearest Relatives can attend Tribunals, they rarely do. Sometimes this is because they want to distance themselves from the legal process, or do not wish to confront their detained relative. It can be difficult to side with the psychiatrist and AMHP when their patently unwell relative is protesting that they do not need to be detained. The patient may not be able to recognise that their relative may really have their interests at heart, or may even be frankly terrified of them.

I have attended a few Tribunals where the Nearest Relatives have had a crucial role to play in assisting the Tribunal members to reach a decision. Sometimes this has been by the relatives telling some harsh truths about the patient. Sometimes they have facilitated their discharge in the face of opposition from the professionals.

Doreen was a woman in her early 60’s. She had a history of bipolar affective disorder going back nearly 40 years. During that time she had had a number of acute admissions under the Mental Health Act, most recently about 6 years previously. She normally managed well with a fortnightly depot injection and some oral mood stabilising medication. In fact she literally swore by its efficacy: “That injection,” she once told me, “it’s fucking marvellous!”

Doreen was a large and imposing lady. Even when well, she probably ran a bit fast: she was always loud, and often very crude, but in an amiable and rather likeable way. She tended to fill a room, both in reality, because of her bulk, but also with her gravely voice, which had been roughened and deepened by her 50 cigarettes a day habit, and her frequent peels of laughter after having told a particularly off colour joke.

It as unclear what had precipitated this admission; her husband thought that she had stopped her medication because of fears it was causing her constipation. The result, however, was that her behaviour became more and more unmanageable by her usually very tolerant husband, and even the input of the Crisis Team could not prevent an admission to hospital. When she decided to leave a few days later, she was placed under Sec.3.

Outraged at this, she appealed.

She had a manager’s hearing within a couple of weeks. I wrote her Social Circumstances Report. I interviewed her husband, who told me that he thought she needed a combination of oral and injected medication. He did not feel she was well enough to be at home at present. I put this in my report. When I interviewed Doreen for the report, she was still clearly displaying symptoms of hypomania, talking very quickly, darting around from subject to subject – and also displayed symptoms of paranoia, focusing on ward staff and her husband. The ward staff, she confided in me, were trying to kill her. She had a fixed belief that the nurses were “wicked animals” who had left her for dead suffering from hypothermia. Her husband, she told me, was a wicked old man who was also trying to kill her, in order to inherit her jewels.

The manager’s hearing considered her case, but did not discharge her from detention.

Doreen remained on the ward, protesting that she did not want oral medication. She continued to be happy to have her depot injection, as she always had been, but she became more and more unmanageable on the ward, being openly hostile to female staff, at times slapping nurses as they passed her in the corridor, and was also sexually disinhibited with male staff and patients. The ward decided to transfer her to the local PICU (Psychiatric Intensive Care Unit).

The PICU is classified as a low secure unit. This means that it is locked. I attended her first review. I had to go through an airlock, leaving any sharp objects, keys, and my mobile phone at reception. Doreen was still voluble and showed evidence of hypomania, but was not being verbally or physically aggressive to staff. She did, however, attempt to seduce the male nurse who was present at the meeting. She continued to refuse oral medication, but appeared more settled. After about a month a date for a Tribunal was set.

I interviewed both her and her husband for the report. He told me that he was willing for his wife to return to the marital home, as long as her mood was stable and she was complying with her medication. Certain areas of need have been identified, including some aids and adaptations to the house, and a support worker to take Doreen out. He was also considering taking early retirement in order to spend more time with her. Doreen's mental state did seem to have improved, but there was still evidence of pressure of speech, as well as evidence of disinhibition in the content of her conversation with me. Her relationship had clearly improved with her husband, who had been visiting her on the ward. However, she remained adamant that she should never have been detained, and that she did not need oral medication. I concluded in my report that "although I am aware of some improvement in Doreen's mental state, she is still presenting with a mental illness of a nature and degree that warrants her continued detention under Sec.3, and that were she not detained under the Mental Health Act she would intend to leave the ward and return home. This would not be in the interests of Doreen, or her nearest relative and carer, and could jeopardise her long term rehabilitation prospects." I suggested that she should return to the local ward prior to her eventual discharge home.

When I arrived at the PICU, not only was her husband there, but her daughter and son-in-law had also come. Although her husband had told me only 2 weeks before that he still had worries about her returning home, he was now saying that he wanted her home as soon as possible. They all went off into a side room with Doreen’s solicitor.

With Doreen's consent, her husband and daughter both attended the Tribunal. The solicitor invited them to give evidence to the Tribunal regarding the arrangements they could make to care for Doreen and maintain her mental stability. They were prepared to take her home with them today, were the Tribunal minded to discharge her.

The Tribunal were so minded, she was discharged for the Sec.3 with immediate effect and she went home with her relatives that day.

And reader, to this day Doreen is still at home with her husband, still in good mental health, still accepting her depot injection, and still not taking any oral medication.

Thursday, 7 April 2011

Despite the title of this post, I’m not completely gamekeeper turned poacher – as an AMHP I do take the view that some people with severe mental disorder need to be detained under the Mental Health Act for assessment and/or treatment. However, if you are a detained patient who does not want to remain in hospital, here are some hints and tips that might make your stay a little shorter.

1. Appeal against your detention
When you are detained under a section of the MHA, it is the duty of the AMHP who detained you, and of the hospital staff, to inform you of your rights to appeal. Staff have a duty to help you if you want to appeal. Your case will then be heard by an independent Tribunal which is part of the judicial system. Around 15% of appeals to Tribunals are successful.

A formal appeal to a Tribunal will also concentrate the mind of the psychiatrist. If you are making a good recovery, they may well decide to discharge you from detention prior to the actual date of the appeal.

2. Get a solicitor
Patients detained under the MHA have the right to free legal aid regardless of their incomes. There are solicitors with special training who will take on this work. The hospital staff will put you in touch with an approved solicitor. Although a patient can use almost anyone to help them present their case in a Tribunal, your chances will be improved by having a qualified legal representative.

3. Allow the solicitor to present your case
Although Tribunals make an effort to appear as informal as possible, it is nevertheless essentially a court of law. The chairman of the Tribunal, whose status is equivalent to a judge, will not appreciate the patient making constant interruptions or challenging the testimonies of the psychiatrist or AMHP. The patient can ask their solicitor to point out inaccuracies or discrepancies in written and verbal reports. The solicitor will frequently pick up on these issues without prompting. Don’t make the mistake that Norman did (When Detained Patients Appeal Part II, 16th March 2011).

4. Be wary of opportunities to speak to the Tribunal
I’ve seen many cases appear to go well in the Tribunal right up until the moment when the patient is asked by the medical member or the chairman to tell them more about how they are or if they have anything they wish to say to the Tribunal. Many a paranoid or psychotic patient has then gone into great detail about their delusions or hallucinations, thereby proving that they have a mental illness “of a nature or degree which warrants detention in hospital” for assessment or treatment, and which would then make it very difficult for the Tribunal to discharge them. Don’t make the mistake that Denise did (Just Another Day, 3rd September 2009).

I remember one Tribunal I attended. The patient had sat there quietly throughout, allowing his solicitor to question the psychiatrist and his care coordinator. It had been going quite well for him. The solicitor had certainly made the psychiatrist look uncomfortable at times. The medical member then said to him: “Is there anything you would like to tell us?”

“Yes,” he replied. “I don’t need any medication or anything like that. I’d be perfectly all right if it wasn’t for these voices. They never leave me alone. They’re always going on at me to do bad things. I think it’s my psychiatrist, he projects them into my head from a transmitter on his desk. I had a brain implant inserted into my head many years ago which has made me half robot and half human. The implant picks up the signals and I then hear them. Those voices, they drive me mad, I tell you.”

He did not get off his section.

5. Do not threaten or assault the psychiatrist or other staff
This does not look good in a report to the Tribunal. It will also tend to stay with you in every future risk assessment.

6. Take the prescribed medication
Psychiatrists do as a rule want their patients to get better. Nowadays there is intense pressure on hospital beds, and psychiatrists do not generally want patients to remain in hospital longer than absolutely necessary. There is a wide range of psychotropic medication that can actually help people with depression, psychosis or mania with their symptoms. Cooperating with the inpatient treatment plan and with plans for your aftercare after discharge will definitely make your stay shorter.

If you are detained under Sec.3 (for treatment) you will inevitably be subject to Sec.117 of the MHA. This refers to the duty of the NHS and the local authority to provide aftercare. The cost of any aftercare provided (including residential or nursing care, as well as provision of community support services) will have to be met by the local authority or the local NHS Trust.

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.